Self Direction

Self direction is a way of delivering HCBS that allows individual beneficiaries to directly control a range of services and supports (with the help of representatives, if desired) based on that individual’s own preferences and needs, and with the goal of maximizing independence and the ability to live in the most integrated community-based setting.  Approaches to participant direction may include employer authority over personal assistance workers and budget authority over HCBS service delivery, or both.  Although self-direction is an optional delivery mechanism for most Medicaid funded programs, programs that propose to integrate LTSS into Medicaid and Medicare managed care must be required to prioritize the preservation and further enhancement of self-directing options.

Self-direction should be part of an overall person-centered planning process, and necessarily encompasses specific principles and protections around respect for enrollee choice and the right to appoint and work with a representative that are listed in the section on Person Centered Planning.

  • MCOs must continue to offer self-directed HCBS options that were in place prior to implementation of managed care.  This includes a continuation of individuals’ specific employer and budget authority, for instance:
    • Hiring, firing, training, and supervising personal assistance workers.  This includes recruiting, interviewing and setting or negotiating work schedules and tasks, and evaluating job performance.
    • Controlling and using funding that would otherwise be controlled by an agency.  This includes setting wages and benefits for workers within program guidelines, and purchasing goods and services to reach an individual’s goals (e.g. assistive technology, home modifications, laundry services, and wellness supports).
  • Self direction must be available to all individuals regardless of age, disability, functional limitations, or cognitive abilities.
  • MCOs must provide objective information, training, and decision-making tools to assist individuals who use HCBS services to understand self direction and implement it to the extent they choose.
  • Individuals must have access to full information, and assistance as needed or desired, to make informed decisions about all aspects of participant direction.  Individuals should be provided with appropriate supports such as financial management services and training to facilitate participant direction.
  • Individuals must be permitted to choose to hire family and friends as HCBS providers.  MCOs must support flexible hiring, training, and worker qualifications that respect self direction and help to expand the long-term service work force.
  • Individuals must have the right to take risks and the responsibility to develop or help develop a back-up plan for assumed risks and for emergencies.
  • Individuals exercising budget authority should have the opportunity, but not the obligation, to budget for and save funds for emergency needs (e.g., emergency vehicle repairs or travel related to family illness) and large purchases (e.g. home or vehicle modifications) with the intention of supporting independence and avoiding unnecessary institutionalization.
  • Individuals’ self directed budgets and plans are developed to include other services and supports as obtained, such as housing, and allows funds to be used in combination with those resources realized from other programs.
  • Individuals who use HCBS must have a central role in the ongoing development of quality measures for HCBS, including the determination of appropriate worker qualifications, training, and individual outcome measures.
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